GP Cluster Action Plan 2016-17 City Cluster 1 P a g e
Welcome to the City Health Cluster Plan for 2016/17. The City Health, based in Swansea, comprises ten general practices working together with partners from Social Services, the voluntary sector and the ABMU Health Board. 2 P a g e
The City Practices, in line with other networks in Swansea, aim to work together in order to: Prevent ill health; enabling people to keep themselves well and independent for as long as possible. Develop the range and quality of services that are provided in the community. Ensure services provided by a wide range of health and social care professionals in the community are better co-ordinated to local needs. Improve communication and information sharing between different health, social care and voluntary sector professionals. Facilitate closer working between community based and hospital services, ensuring that patients receive a smooth and safe transition from hospital services to community based services and vice versa. In order to support the development of the Cluster Plan, information has been collated on a wide range of health needs within the City area. The summary below highlights the key points and this information has been used to inform the development of priorities for the plan. The 10 Cluster practices serve a varied population of 51,372 that has: High deprivation levels; with 24,833 (49%) residents living in the most deprived fifth of areas in Wales (see Deprivation Comparison below) Large student, asylum seeker and multi-racial/multi-cultural groups A large proportion of young parents 7,920 patients aged 65+ (16%) and 1,060 aged 85+ (2.2%) A 8% obesity rate (ABMU average is 9%) The highest percentage of smokers (30%) across Swansea (20%) {GP register data} An Incidence rate of 195 per 100,000 population for referrals to drug and alcohol treatment services Bowel Screening uptake of 43.4% (Target 60%) Lowest in Swansea Cervical Screening uptake of 70.3% (Target 80%) Lowest in Swansea The highest number of A&E attendances of any network in Swansea The second highest rate in Swansea of emergency inpatient admissions The highest rate of prescription of anxiolytics and hypnotics, antidepressants, opioid analgesics, tramadol, NSAIDs in Swansea The area is served by: 4 General Dental Practices 1 Specialist Orthodontic Practice 1 Specialist Dental Practice (Sedation and Oral Surgery) 15 Pharmacies 6 Opticians 4 Nursing/Residential Homes 10 Schools 3 P a g e
Strategic Aim 1: To understand the needs of the population served by the City Cluster No Objective Action Key partners For completion by: Outcome for patients Progress to Date / Current Position RAG 1a To improve Primary and Community services for Frail Elderly/Falls Ensure continued strong links are maintained with ACR. ACO ensure full awareness of ACO GPs is embedded with all practices. Continue to promote the falls prevention service and evaluate referrals. Continue to distribute Falls Prevention guide and evaluate uptake. Anticipatory Care: Establish systems to: Identify those most vulnerable of losing their independence Identify care coordinator and care plan systems Develop effective means of communication Hubs s to liaise with Acute Response Team Community Hubs/older peoples mental health services Quarterly checks. To improve community care and reduce number of falls Early identification of those patients most vulnerable of losing their independence. Care coordinator and care plan systems will assist those patients most at risk. Falls prevention guide has been produced and has been delivered to all practices for patients to prevent and support individuals who are at risk of falling. Practices counting referrals to evaluate service. Hub Manager and Lead Nurse attending all meetings. 1b Support Community Services. Continue supporting delivery of comprehensive patient discharge summaries to Bonymaen House. Practices Health Board Community Services Safe and appropriate care. Residential Care Assessment Beds information leaflet produced and distributed to all Swansea practices. 4 P a g e
1c To improve Sexual Health services for patients. To provide specialist services e.g. IUCT, UCD, Implanon with abilities to crossrefer between practices.. 1d Smoking Signpost smokers to Public Health Level 3 Pharmacy Scheme and support with Public Health materials. Chair Health Board Public Health Wales & Allow patients to access contraception services in a local general practice. Reduction of smoking rates within the will continue to support and monitor referrals. When convened, Pharmacy Steering Group to be asked to collate source of Level 3 referrals in order to reflect the work that is being undertaken by GP s. Highlighted on Community Pharmacy Wales newsletter. 1e Substance Misuse Health board to sign off revised version of draft LES Relaunch once confirmation received. Health Board Improved access to substance misuse services. TK to progress. 1f To support newly diagnosed diabetic patients (and those pre-diabetic patients) in undertaking lifestyle changes which will benefit their health and wellbeing To embed the Weight Watchers/Positive Steps programme across the To proactively review the number of patients being referred by the practice to NERS/Weight Watchers. Need to investigate low uptake of service. GPs Weight Watchers Positive Steps PHW HB Quarterly Better health for those patients with chronic diseases. Improved lifestyle choices leading to a less medical model of care. Engage with Public Health/Third Sector. Maintain links with Weightwatchers Programme to receive progress reports at regular intervals. December 2016 reports indicate that only 3 practices signed up and only 11 patients referred. TK to lead review of service. 1g To improve access to mental health services Understand level of mental health nursing input across practices. SCVS Health Board Improved, timely access to mental health Amended criteria so that Type 2 Diabetics 5 years+ can access service. Counselling start 1 st Nov 2015 Patient survey prepared for 5 P a g e
To continue to provide in house counselling services. To further develop the LMPHSS information clinic within the City and explore new ways of working e.g. Development of Mental Health focussed Noticeboards/Information Provision within the GP Practices GP practices services Improved access to counselling services for patients who need Tier 0 support either via practice or network level distribution 10 patients per practice. Agreed to cap referrals to 6 sessions per patient. Exercise underway to look at different model options for future counselling service. Signposting patients to Tier 0 services Develop service for all practices to receive LMPHSS All practices to use counselling guides developed by SCVS as a resource. 1h Increase uptake of bowel and cervical screening Continue to raise awareness of bowel and cervical screening programme. Advertise via posters and leaflets provided by cervical screening; including GP practices, community pharmacists and local authority buildings. Practices Community Pharmacies Local Authority Mar 17 Increased cancer detection and earlier diagnosis; reduce avoidable deaths. Current screening uptakes of: Bowel Screening 43.4% (Target 60%) Cervical Screening 70.3% (Target 80%) 1i Increase flu immunisation uptake Compare actions of best-performing City practices. Lower performing practices to work with PHW Discuss schemes in place/share good practice across practices that increase high uptake and how they manage PHW Practices Community Pharmacies Mar 17 Protect patients at risk and the wider population. Results of bowel screening pilot to be presented at May 2017 meeting. PHW assisting practices to improve uptake. Good practice discussed. Key success factors identified as : GP Immunising 6 P a g e
defaulters. Flexible clinic times Personal contact to patients Fluenz included in spending plan. PHW advise improvements shown all around. Data shared with practices and best performers sharing approach with colleagues. 7 P a g e
Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients (WORKFORCE) No Objective Action Key partners For completion by: 2a Ensure that access Continue to review access practices Quarterly arrangements are in arrangements and Primary Care with Kingsway as place that meet the Foundation work. (Re-evaluate) link. reasonable needs of Consider staffing/workforce practices Quarterly local patients pressures. Outcome for patients Services developed to reflect local need Release more capacity for patient care. Progress to Date / Current Position Discuss at future meetings. RAG Look to employ Dressings Nurse. Mar 17 Appointed 6 th March 17. 2b 2c Address Homelessness Service continuation and improvement. Possibly develop the as a Federation Accelerate the development of the network and maximise the potential of working together, through ensuring implementation of network driven projects and schemes, and developing business of the network to meet its potential. Use slippage money to set up additional PLTS session to discuss. Invite facilitator. Employ Implementation and Business Development Manager Create work plan for post. Health Board ABMU Service operating from High St, Central Clinic and Access Points. HHAVGAP supporting Mar 17 Information documents circulated. PLTS session arranged with Llwchwr. Pen Y Bont and Blake Morgan sharing experiences. Mar 17 Post appointed 21 st Feb 17. Introductory meeting held 14 th March 17. Work plan developed. 8 P a g e
Strategic Aim 3: Planned Care- to ensure that patient needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms No Objective Action Key partners For completion by: 3a To adopt a dementia friendly approach To undertake dementia friendly training for City practices To identify early signs of dementia, improving read code in practice and to encourage patients to attend memory clinics. Social Services, Third Sector GP Practices Outcome for patients Improved awareness and understanding of dementia leading to improvement in service delivery. Progress to Date / Current Position All practices have attended dementia PLTS. Read codes supplied to practices for monitoring. RAG 3b To improve access to dermatology services within the community, therefore reducing the number of patient referrals to hospital Ensure dementia boards are being used. GPs to be up skilled and receive appropriate training in the use of dermoscopy and its technique. Use of cluster monies to purchase dermatoscopes and a camera package for each practice. BSM to ensure set up of cameras for each practice. Jeanette Munn. GP Practices LHB Sep 16 Less secondary care referrals. Better service for patients. Dermoscopy training session being arranged. Practices have purchased dermatoscope packages. LHB to reimburse practices for cost of units from monies. NWIS trialling Webcam software for EMIS and Vision. 9 P a g e
Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the continuous development of services to improve patient experience, coordination of care and the effectiveness of risk management (UNSCHEDULED CARE) No Objective Action Key partners For completion by: 4a To reduce the To improve patient education e.g. GP OOH inappropriate use of display posters A&E A&E and GP Out of MIU Ours Link in with alternative services e.g. HB AGPU and ACO. Community Voices Outcome for patients Better education on how to access services appropriately to meet their needs Progress to Date / Current Position ABMU Communication Team has become involved with surgeries and assist in providing correct information. RAG 4b Reduce hospital admissions Signpost patients to ensure attendances are appropriate including e.g. Choose Well posters Use of discharge summaries Proactive care; Anticipatory care Use of pathways Use of email advice lines Use of telephone advice lines Signpost to other community-based options (more amenable to patient) Refer to ACO/ACR Take up of the anticipatory care pilot. Secondary Care Primary Care Community Care More appropriate streamlined care Choose Well campaign progressing in all practices. Practices auditing summaries to forward to Chair. Medical Director advised that Health Care Inspectorate Wales are launching their national review of discharge summaries, on behalf of the Welsh Audit Office s discharge planning review. They are planning to interview our colleagues in ABMU, as well as other Health Boards. These interviews will involve giving examples of when patients have been or put at risk of harm. 10 P a g e
Strategic Aim 5: Improving the delivery of end of life care No Objective Action Key partners For completi on by: 5a Palliative Care- Adopt principles of end of life care with focus on continuity of care relating to patients with palliative condition in last two weeks of life. Develop relationship between Practice/ and Secondary Care: Topic arose following discussion around poor discharge summaries and raised expectation of patient. practices Secondary Care Outcome for patients Reduce significant risks associated with managing discharged patients with no/inadequate information Progress to Date / Current Position Medical Director advised that Health Care Inspectorate Wales are launching their national review of discharge summaries, on behalf of the Welsh Audit Office s discharge planning review. They are planning to interview our colleagues in ABMU, as well as other Health Boards. These interviews will involve giving examples of when patients have been or put at risk of harm. RAG 5b 5c 5d To review the number of deaths as per guidelines Practice level regular palliative care reviews and completion of EOL template Undertake regular audit; sharing results on a cluster network basis Undertake review of number of deaths as per guidelines Undertake review of palliative care cases on a regular basis Regular audits to be undertaken and learning points to be progressed Identification of trends across the networks Identification of good practice and areas of concern National pathway work undertaken between October 2016 and March 2017. All practices discuss and share details of the reviews undertaken, learning points and actions to be undertaken. NB QOF relaxed for this year. Feedback being offered where already gathered. 11 P a g e
Strategic Aim 6: Targeting the prevention and early detection of cancers No Objective Action Key partners For completi on by: 6a Secondary care downgrading USCs Review USC referral downgrades. to collate examples on a network basis to raise to relevant specialties. Outcome for patients Potential earlier identification for patients with cancer Progress to Date / Current Position Chair has collated practice information re downgrades. RAG 6b 6c Address smoking as a cause of cancer To target the prevention and early detection of digestive, lung and ovarian cancers Have agreed for future to: Remind GPs to complete a USC referral in cases of change of bowel habit; Remind GPs to refer as USC on suspicion of cancer rather than awaiting investigations and avoid false reassurance of inappropriate investigations. PHW and Stop Smoking Wales developing a menu of options to compliment Level 3 Pharmacy Scheme. Review patients with lung, digestive and ovarian cancer in line with Cluster Development Domain. PHW Tobacco Action Group TK Mar 17 Improved stop smoking support practices Better prevention and earlier detection of cancers for our patients National pathway work undertaken between October 2016 and March 2017. All practices discuss and share details of the reviews undertaken, learning points and actions to be undertaken. Public Health Wales developing a new suite of services for 2017-18. 12 P a g e
Strategic Aim 7: Minimising the risk of poly-pharmacy No Objective Action Key partners For completion by: 7a 7b 7c To progress polypharmacy issues identified in previous cluster network plan To ensure appropriate use of the pharmacist and technician resources (cluster and non-cluster funded) to reduce risks from polypharmacy and improve other aspects of medicines management To engage in the Prescribing Management Scheme (PMS) and PMS+ respiratory schemes (which contain polypharmacy elements). PMS+ respiratory extended for 1 year from Jan 2017 To progress polypharmacy issues identified in previous cluster network plan. Cluster Pharmacist to offer recommendations for future work. Work with medicines management team to deliver and ensure appropriate training, support and indemnity arrangements Undertake a range of prescribing initiatives to improve: respiratory, antibiotic, pain management prescribing and yellow card reporting. Discuss use of PMS+ savings monies. Medicines management team and Practice Teams Medicines management team and Practice Teams GPs Practice Nurses Medicines Management team PMS 16/17 by March 17 (some Dec 16 deadlin es) PMS +respira tory by Nov 16 PMS+ by January 2018 Outcome for patients Improved prescribing and mechanisms for polypharmacy review Improved access to better pharmaceutical care Improved medicines management including polypharmacy Investment in other service areas for patient benefit Progress to Date / Current Position work in practices also supported by the Medicines Management team. Cluster Pharmacist appointed as well as other support from Health Board Medicines management team Work ongoing to clarify roles, training requirements and indemnity arrangements Discussed at all annual practice prescribing visits Practices engaged and making progress Medicines management team supporting where possible RAG 13 P a g e
7d 7e 7f To provide standardised training for prescribing clerks and seek opportunities to build on initial training to further develop staff Improvement/mainte nance against national prescribing indicators To improve antimicrobial stewardship through appropriate use of antibiotics Nominated clerks to complete training packs Seek further opportunities to develop staff Consider and review practice and network data for national indicators Implement mechanisms to ensure appropriate use of antibiotics (see also PMS 2016-17) Medicines management team Practice Managers Prescribing Clerks Practice teams Medicines management team Practice team Big Fight Team Medicines management team Completion of packs - June 2016 within 16/17 with monitoring of trends See also PMS 16-17 for deadlines: Dec 16: Overall antibiot ic use and choices Acute Cough Audit Improv ement Plan March 17: Evidenc Improved repeat prescribing systems Improve prudent prescribing leading to better health outcomes and reduced polypharmacy Reduced antimicrobial Resistance Reduced C.Diff Increased knowledge and empowerment to self care Number of clerks completed: Bay: 39 City: 23 Cwmtawe: 18 Llwchwr: 17 Penderi: 16 Discussed at all annual practice prescribing visits Work ongoing with the Medicines Management and Big Fight team Discussed at all annual practice prescribing visits. Development of cluster level data available on GP portal Reductions in levels of prescribing have been demonstrated across all Swansea networks. City range from -16% to +2% Overall reductions of 7% 14 P a g e
7g Direct supply of dressings to Central Hub for community nurses, reducing need for GP prescriptions and aiding compliance with ABMU formulary Medicines Management Team & Community Nurse Teams e of patient engage ment activitie s with review at 6 months Timely access to most appropriate wound care dressings, reducing delays for patient treatment and nurse time in sourcing products Project commence July 2016 Reviewed January 2017 Initial review shows cost neutral for dressings however benefits lie in reduction in GP time/nurse time and pts receiving dressings at the right time without delays. 15 P a g e
Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance (Inc. PREMISES) No Objective Action Key partners For completi on by: 8a 8b To ensure that premises are fit for purpose within network Ensure robust systems at practice level To ensure that risks and opportunities are flagged are identified within the Health Board s Primary and Community Estates strategy. Ensure that CGPSAT toolkit, significant event analysis are undertaken, results shared to ensure best practice. Practices to share SEAs at meeting to share learning. Health Board, s, Local Authority, Coastal, WG, Shared Services Partnership Outcome for patients Premises fit for service provision s/practices Safe environment for patients Progress to Date / Current Position Raised in Practice Development Plans. To address through Estates Strategy. Sharing event at each meeting. RAG 16 P a g e
Strategic Aim 9: Other Locality issues No Objective Action Key partners For completion by: 9a To ensure that impacts of population change are planned for Scope for population increase e.g. housing/student developments and include mitigating action in future plans, including workforce considerations. Risk particularly to practices on east of cluster who are at maximum capacity already. Participate in LDP discussions and assess impact for City. Health Board (through supportive information provision) Outcome for patients Ensuring suitable provision available. More cost-effective services able to better provide for patient needs. Progress to Date / Current Position Health Board liaising with practices and holding formal discussions with Local Authority through consultation on LDP. Findings presented at March 17 meeting. RAG 9b INR service ensuring dosing and prescribing are not separated Review of INR service to ensure includes NOACs Consider practices collaborating to ensure equitable distribution of new patients Use this as a focus to discuss/plan how the network could share services in future in a federated approach around payroll, recruitment, admin etc. Practices to agree on approach (preferably collectively) with options as follows: - GPs carry out anticoagulation testing and dosing independently - Await outcome of DES consultation and if favourable adopt this approach Implement the Cwmtawe model whereby the service is funded via the Health Board who bear the cost (Anticoagulation Project) LHB GP practices +/- secondary care services +/- HB medicines management teams March 2017 at the latest Safer services through not separating roles of monitoring and prescribing in line with MHRA. Improved time in range. More accessible and patient centric service. NIBDM scoping for opportunities PLTS session arranged with Llwchwr. Pen Y Bont and Blake Morgan sharing experiences. Now in process of reviewing options for an ABMU-wide service led by new Medical Director. Options include a practice led National Enhanced Service and a Health Board managed clinic following the Cwmtawe model. 17 P a g e
Strategic Aim 10: Third Sector/Partnership Working No Objective Action Key partners For completion by: Outcome for patients Progress to Date / Current Position RAG 10a To further develop the Third Sector support project, increasing the use of voluntary sector services by the City population Ensure that links are made with voluntary sector organisations supporting the agreed network priority areas where possible. SCVS to map Third Sector provision against network priorities. Maintain consideration of funding Third Sector support via slippage monies. To review arrangements in relation to third sector organisations attending GP practices and agree a way forward for the. Led by practices supported by SCVS Led by practices supported by SCVS and Voluntary Sector organisations. Mar 17 Improved support and access to services. Third Sector Grant Scheme piloted. A total of 10,000 has been allocated to the grant scheme. The priorities of which were Support for Asylum Seekers and Mental Health Provision. It has been agreed to allocate 10,000 to Ethnic Youth Support Team, which will fund an Asylum Seeker Support Worker (0.4WTE) that will work within the GP Practices within the City Cluster. SCVS liaising with practices. 4 GP Practices currently participating. Information stands will be commencing from the week commencing 6 th March 2017 To extend voluntary sector presence within GP practices in the network by increasing the number of practices participating, Healthy Partnerships and exploring new ways of working jointly such as pre bookable appointments where possible. and SCVS 4 GP Practices currently on board. Information stands will be commencing from the week commencing 6 th March 2017 18 P a g e
10b To obtain patient and carer views on network services and priorities programme To establish a patient/ carer participation group within the network area in line with the Community Voices programme SCVS Responsive services taking into account service user and carer feedback. There are fourteen individuals registered with the City Patient & Carer Participation group, but attendance has been low. Members who have attended the group meetings so far have included representatives from Mayhill Surgery, Harbourside Health Centre and the Kingsway Surgery. Topics which have been discussed within the group so far have been: Mental Health Services Cluster Plans Big Fight Campaign 10c Develop Local Area Coordinator (LAC) pilot ABMU to work with LACs to provide clear eligibility criteria for referring patients. Practices to actively refer patients where suitable. ABMU to assist in promotion of LAC project to practices. Health Board LAC practices Communities First programme is ending and current activities to be concluded by end of June 2017. A new programme will be funded which will be focused around empowerment and employability. The fund awarded will be a significantly smaller budget so the new programme developments will be underway in the next few months. Improved support LACs now working in City practices and making links. LAC s have post codes of each area to pass on to GP s/practice managers in area. Provides guide of can person seen be referred to LAC and if so which one. 19 P a g e
10d Develop closer working links with Communities First Increase the use of Communities First services by the City population Ensure up to date information about Communities First is displayed in GP practices e.g. leaflets and posters To ensure that practice actively refer patients to Communities First where suitable. Activities include learning, physical activity, volunteering and community engagement Explore the potential for joint projects where patients would benefit from an integrated approach. Communities First Practices Improved support and access to services for the City population Contact details and Citizens Advice information for C1st clusters circulated to all members. During the last quarter of the 2015 16 delivery plan a counselling service was offered to clients in two Cluster areas (East and West). This service has not continued into 2016 17 because of the change in project delivery and the uncertainty of funding for the future. 10e To increase the use of the Healthy City Directory within the network To increase the use of the Healthy City Directory within the network NHS Direct Health Board SCVS Voluntary Sector organisations population more informed on available health and well being services leading to increased usage To promote the use of the Healthy City Directory within practices and to patients 20 P a g e